A. Problem Analysis

1. What was the problem before the implementation of the initiative?

Thailand is an upper-middle income country in South-East Asia which has achieved impressive economic, social, and health improvements in the past ten years. Between 2007 and 2011 its gross domestic product grew by 7.8%, the percentage of people living below poverty line decreased from 21% to 8.1% between 2000 and 2009, and under-five mortality reached a record low for a country with 13 deaths per 1000 live births in 2010. Non-communicable diseases are estimated to account for 71% of all deaths with cardiovascular diseases representing 27%, cancers 12%, and diabetes 6% of all deaths.
Data from the five National Health Examination Survey (NHES) indicate that prevalence of diabetes in individuals aged 15 and over has increased over time from 2.3% in 1991 to 4.6% in 1997, to 6.8% in 2004, 6.9% in 2009 and to 9% in 2014. Nowadays, diabetes afflicts an estimated ten million people in Thailand over 60% of patients with diabetes have an average glucose (HbA1c) over than 7%. An average glucose less than 7% that is the magic numbers of Thailand service plan policy for diabetes as same several countries. Although advances in medicine can improve diabetes health outcome but recommendations for care are often neglected.
Diabetes disease management which promotes patient involvement and co-ordinated care may increase compliance with recommended guidelines. Information technology (IT) and Novel Innovation (NI) represents key tools in this problem. The growing body of medical service of diabetes management programs is particularly needed an informatics technology backbone in order to effective management. The advantage of IT and NI approach include promoting better guideline compliance by helping of identity hospitals overdue for care and provides to proactively reach out of then: enabling diabetes care center to manage their own care through education and communication tools that allow them to receive elative direct feed-back and providing numerous benefits to their diabetes patients.
If there were publicity available national repository of relevant clinical knowledge, in such forms as alert and reminder logic and report specification, then a substantial cost would be lifted but the benefit picture for diabetes management might improve.
The center of excellence (COE) in diabetes in Rajavithi hospital, a public tertiary center that take care of referred complicated diabetes care from the most of provincial hospitals in Thailand. Team operated a severe complicated care of diabetes more than 1,500 cases a year. From Thailand Diabetes Registry(TDR) prevalence (Rajavithi hospital was site in TDR) of Lower Extremities Amputation (LEA) was 1.5%. Mean diabetes duration was 10 years (SD = 7.6). Out of 556 patients with a history of foot ulcer 123 (22.1%) underwent amputation. Most of LEAs were toe amputations (64.1%) that showed conventional model in tertiary center of Thailand cannot be applied to improve management for diabetes.
In remembrance of His Majesty King Bhumipol Adulyadej; “Rajavithi” meaning to the footpath of the King, our father who had many inventions generated concrete benefits for Thai communities, having been put to practical use in range of several development projects in Thailand as way to follow. With exceptional insight, intelligence, and inspiration, His Majesty has taken natural tract (same as the meaning of our hospital) for the sciences and applied them directly to serve the people of the kingdom of Thailand. Rajavithi Hospital adopted his solving problem concept by development must burst from within. Name of our hospital Rajavithi meant to “The path that following the King”. Rajavithi Diabetes team supposed to be the footpath of diabetes service for our country by developed knowledge and innovation from inner power proved our pathway.

B. Strategic Approach

2. What was the solution?

The ascent of Data mining and instinct it afforded does tip the balance. If diabetes health care system seamlessly combined instinct, experience and data in every decision to solved unplanned diabetes situation in both personal and professional approach. The sustaining and efficiency innovations can be tremendously supported by data as they provide with necessary insight on things that diabetes preference.

3. How did the initiative solve the problem and improve people’s lives?

Thailand Diabetes registry (TDR); A cross-sectional, multicenter, hospital-based diabetes registry was carried out from April through December 2003. The participating centers were university-based and tertiary-care hospitals.
Rajavithi Diabetes registry is different registry from TDR by tracking up to 5,000 urban patients in Bangkok with diabetes and store information specific to their care. Registries may generate concise patient reports for clinicians that highlight cases for attention during the office visit and may also aggregate information across the population to generate report charts which show, for example, the proportion of patients with diabetes who had routine eye examination, protein in urine examination, foot examination during prior year, proportion of patient with achieve hemoglobin A1c (HbA1c) level below 7 percent, low dense lipoprotein (LDL) below than 100 milligrams per milliliter and good blood pressure control. A continuous data gathering every year and shows instant data of diabetes KPI that served for public health service in diabetes scheme by 43 files of Thailand health personal in Health Data Center (HDC).
There has been a growth recently in “wearable sensors” and remote monitoring devices. For example, researchers have developed a portable electrocardiogram (ECG) system for high-risk cardiac patients. It uses smart phones attached to heart monitors to transmit heart rhythm data to health providers. Software analyzes the ECG waveforms for possible abnormalities.
Diabetes brings the risk of hypoglycemia, low blood sugar. Most often the result of imbalance between food, exercise, and medications, a "hypo," a low blood sugar reaction, can cause disorientation, unconsciousness, and sometimes, the need for an ambulance. Smart Hypoglycemic warning watch, it is actually designed to monitor the temperature, heart rate and moisture level of the skin; symptoms normally associated with insulin reactions. If it does not detect one of these symptoms, if a low blood sugar reaction occurs without them, the alarm will not sound, and it will probably be of no use to the diabetes.
It is important to emphasize that hypoglycemia is a biomarker of disease burden rather than a true cause of mortality. Regardless of the cause, clinicians need to be aware of high-risk patients who require careful monitoring and less stringent glycemic control. When a hypoglycemic event does occur, it should be treated promptly and with appropriate changes in the treatment regimen to avoid recurrent episodes. Unfortunately hypoglycemia often occurred in older and bed ridden status with serious comorbidity such as stroke and could not call for help to health care worker or family members.
The hypoglycemia warning watch alarm is intended to awaken the user, if there has been a temperature drop, or it is detecting increased perspiration or if it is detecting of increased heart rate. The alarm does not directly indicate hypoglycemia. If the alarm goes off, and, after checking your blood sugar, you find it is in the normal range, the alarm could have been triggered by its wrist band being too loose, by an extreme change in the room temperature, or if the user perspires excessively or exhibits a drop in skin temperature for reasons other than hypoglycemia, as examples, fever, menopause, or as a side effect of medications. Software that helps health providers understand how to deal with particular symptoms and what drug interactions they should avoid are increasingly being viewed more like a reference library than a medical device, calling into question how they should be regulated. Healthcare providers need access to as much accurate data as they can get on how to treat in serious diabetes condition by integrate it together in the same system.

C. Execution and Implementation

4. In which ways is the initiative creative and innovative?

Rajavithi Diabetes Registry and Smart Hypoglycemic warning watch has an integrated function by sending the essential diabetes information (average blood sugar level, medication and comorbid disease) for emergency health care officials who decided to manage hypoglycemic diabetes patients.
Rajavithi Diabetes Registry is purposed to derive diabetes data from paper record to electrical medical record (EMR) by innovating instant results for KPI in diabetes national service plan and helping healthcare provider to monitor, reflect and improve their work using the web base data system. This system brings diabetes data to DHC Thai nation dashboard monitoring in non-communicable disease board. Rajavithi diabetes team developed registry system which was validated in during 2011-2012. In 2014-2015 Rajavithi diabetes team also invented smart hypoglycemic warning watch to help diabetes patients who burden with hypoglycemic events.
Individualized diabetes data transferred to patients when the smart hypoglycemia warning the serious hypoglycemic event to registry system and emergency team. The initiative unique service will bring diabetes care to medical mobility service era.

5. Who implemented the initiative and what is the size of the population affected by this initiative?

Rajavithi Hospital is a 1,200-bed medical center accommodating 40,000 in-patients and 1,000,000 out-patients yearly or a daily average of 4,000 patients, with 200,000 referral patients (both in and out patients) around the country. The hospital provides medical service at standard health promotion in tertiary levels and above, including quality referral system. We have more than 200 medical doctors, over 800 professional nurses and specialized staffs and over 4,000 other supporting staff who are ready to provide medical services in varied specialties and healthcare dimensions.
Rajavithi hospital has strategically developed its advanced medical specialty capacity using expertise in each treatment to further study, analytical research, evaluation, development and transfer know-how to provincial hospitals throughout the country by establishing an information infrastructure blended with an effective referrals system of hospitals under the Ministry of Public Health nationwide. The hospital is authorized for international referrals covering a spectrum of medical specialties serving patients sent from other countries. Our Centers of Excellence have been in professional service over three decades.
Diabetes Quality Team solved diabetes problems by patient centric approach with data system management and transferred to medical innovated devices. Based on data management, team and hospital board have shaping and designing a new solution for innovated diabetes medical service. Our mission is the improvement of quality of diabetes management for poverty and equalization of Thai citizen health.

6. How was the strategy implemented and what resources were mobilized?

During 2011-2012, the first registry system characteristic (phase I) with data management objective. Strategies for achieve by promoting evidence base for gathering the diabetic patient data, improving human resource skill and productivity, and making a move from paper to electronic records.
Diabetes Rajavithi Quality team had creating a registry software for non-communicable disease (NCD) by Academic unit in collaboration with programmer. Registry system conducted on diabetes health care centers of Rajavithi networks and department of medical service (DMS) of health public ministry. Organized training courses by the Academic group and programmer to collaboration with department of medical service of health public ministry to diabetes healthcare center that take care diabetes patient.
Instants result analysis report (Phase II) during 2012-2014, applying modern software for real time result display followed by nation diabetes KPI by transformed paper data to digital data and self-report results for individual diabetes health network center. Registry manual send to network health center registration providers. Organized training course achieved by the Academic group with programmer to collaboration to health care register. Data had collected and showed with prompt results for key performance indicator according to health public ministry policy.
Innovation device for gathering data (phase III) in 2015. Rajavithi had created new innovation devices for collecting the promising data by novel devices, for examples; hypoglycemic warning watch, diabetes foot examination devices and others application. Gathering data from devices send to data center with healthcare diabetes register software. Connecting and sharing data from devices to Rajavithi diabetes registry data. Managing data by connected to register base health care center data.
Integrate diabetes healthcare mobility by Diabetes Registry and Smart hypoglycemic warning watch for emergency diabetes management (Phase IV) during 2016-2017. Strategic approach model development to local area by integrated essential data form diabetes registry to emergency diabetes hypoglycemia and approach to model development in local area. Transforming local diabetes management data to Rajavithi diabetes networks registry to created novel diabetes learning community. Data management, consultation and service development via diabetes registry by local diabetes health care team. Data monitoring, feedback by local diabetes health care them via diabetes registry and telemedicine. Organized meeting among diabetes service plan board, local diabetes health care team and physician, internist or endocrinologist to obtain feedback from analysis data.

7. Who were the stakeholders involved in the design of the initiative and in its implementation?

During 2011-2012, Diabetes registry system conducted by consultant of DMS and director of Rajavithi Hospital for management diabetes data as academic headquarter of DMS by Diabetes quality team(multidisplinary team) worked with programmer to design internet base for diabetes registry. This program could be backbone for several services in outpatient diabetes department.
At the last quarter of 2012 to 2014 this program was introduced to the other collaborated hospital in DMS by using this program for their center result and monitoring KPI that respond to performance in diabetes clinic and prompt responds if KPI is under standard KPI by diabetes service plan such as Priest hospital is a hospital where take care sick monks in Bangkok near Rajavithi hospital. There was only one endocrinologist who take care 1400 monks per year that take care of referred diabetes monks almost entirely of Thailand. Diabetes service team of priest hospital is one of Academic teams of Rajavithi diabetes registry team. An endocrinologist had support this registry system in 2014, she could monitor instant key performance indicator (KPI) from diabetes monks patients. She therefore spent less time in working day to provide new programs for her patients eg: promote urine protein examination for diabetes nephropathy, addition program of foot management care for Deportment of Medical Service to Health Public Ministry.
Innovation device, smart hypoglycemic warning watch invented in 2015 by Diabetes Quality team with biomedical engineers. The National Innovation Agency (NIA) supported grant for an innovative research that conducted by Rajavithi quality team and commercial company for finding the solution combined the diabetes data registry to innovation device transformed this initiative idea to healthcare mobility solution that take responsibility for emergency condition of diabetes such as hypoglycemic event.

8. What were the most successful outputs and why was the initiative effective?

Based on our data on hypoglycemia in diabetes patients, problem often occurred in vulnerable group of diabetes patients who can manage a serious complication by calling for health in severe hypoglycemia attack that may be caused of death in their treatment.
The Department of Medical Services, Ministry of Public Health has launched the good governance recognition in 2007. In 2010, a development of referral and bio data system of diabetic patients by internet was successfully launched nationwide. During 2015-2016, Diabetes Registry system (Head) was one of 3-H (Head-Heart-Hand) model for Rajavithi diabetes care team and innovated invention; smart hypoglycemic warning watch received a service outstanding award and innovation outstanding award by the Office of Public Sector Development Commission respectively. This is a new tool that enhances the accessibility to quality and safety, effectiveness and affordable device and healthcare service. The combination of diabetes registry and innovation device is the novel innovation to enhance the response to diabetes emergency dimension for combatting a serious complication such as hypoglycemia and/or emergency cardiovascular disease events in future. This innovation could reduce the amount of procedures and paperwork necessary to benefit from health services, reduce the cost of certain health service while increasing the quality of service delivery. This is the way to make health service to relevant, responsive to diabetes needs and engage diabetes healthcare official in decision, implement and evaluation of health service delivery.

9. What were the main obstacles encountered and how were they overcome?

Diabetes is not only one disease but it is complex diseases and too often leads too serious potential life-threatening complication such as the cardiovascular and kidney disease as well as nerve damage, amputation, blindness and multitude of other health problems. Clinical registry will ultimately allowed to improved quality of care and quality of life for all people living with diabetes by giving researcher and clearer picture of what’s happening to patient at various stage of their disease. Improve data collection should have improved patient outcomes.
Rajavithi Diabetes registry differs from the other registry by fully computerized and include information for the entire Rajavithi hospital and collaboration center. Because it is ongoing project and not simply a cross-sectional survey, it can identify trends in glycemic control for any given patient, as well as for patients who are becoming lost to follow up. The database is accessed to signal when patients have poor glycemic control or are receiving inadequate monitoring (annually microalbuminuria screen, ophthalmologic examination and foot examination). The main obstacles are workload for registry clerk and different data record from different report system such as in public ministry record via DHC base program but in Bangkok metropolitan hospital report in another program. Diabetes Quality team and registry programmer find out the solution to import specific platform from different programs to Rajavithi Diabetes registry platform to report result in the same pattern outcome.
Innovative device, smart hypoglycemic warning watch, Base on observational research of Rajavithi hospital about hypoglycemia event during 2011-13 that showed severe hypoglycemia we found 67% that after adjusted favorable factor to involved hypoglycemia we found status bed-ridden was independent risk factor of severe hypoglycemia that why we thought to solved this problem by new innovation product from our research. Our team invent of warning watch from physiology respond by sensor variable of hypoglycemic response by biomedical engineer team with store data in web base program to monitor by telemedicine and nursing care team.
Novel healthcare mobility involves the use of mobile devices, applications, and enterprise platforms to communicate as well as securely and more efficiently exchange diabetes clinical data among various end users such as payers, providers, and patients. The use of mobile technologies and applications can help make this transition across healthcare facilities, resulting in fewer hospitals readmissions and better patient outcomes. Mobility solutions allow workers and staff of the healthcare ecosystem to access all kinds of information while controlling costs and managing risks of diabetes such as hypoglycemia response service from Rajavithi hospital.

D. Impact and Sustainability

10. What were the key benefits resulting from this initiative?

NCDs such as diabetes, poverty-related illnesses are relatively straightforward in terms of causation and can often be prevented by investments in infrastructure and public health initiatives at the household or community level. Treatment can be provided with relatively inexpensive equipment and drugs, and health workers do not necessarily require many years of training. As such, the major stumbling block to eradicating these kinds of diseases is not so much the availability of technology and highly skilled personnel, but the commitment of resources to improving the living and working environments of the poor and the provision of basic community health services.
In Thailand, according to epidemiological monitoring reports from the Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health in 2006-2007, there are 643,522 diabetics and 131,058 (20.4%) patients with complications in 2006, which increased to 757,031 diabetics and 159,403 (21.1%) patients with complications in 2007. There is also an increasing rate of hospitalization due to acute complications among diabetics aged 15 years and older, from 64.6 per 100,000 in 2005 to 74.3 per 100,000 in 2006, and 98.8 per 100,000 in 2007. Diabetic patients who had hypoglycemia at home at least once were at 8.83 times greater risk for hypoglycemia requiring hospitalization (95% CI: 2.58 - 30.20) than diabetes who had never had hypoglycemia at home from Northeast hospital in Thailand. Several previous studies have found that the group who lacked awareness of hypoglycemia had high rates of severe hypoglycemia: 5.1 and 9.6 times when compared with the group with normal awareness. The study in Rajavithi Hospital due to hypoglycemia between June 1, 2012 to October 31, 2014 (n=14,268) diabetes mellitus type 2 patients admitted that found status bedridden seems to be the only factor that predicts the development of severe hypoglycemia in which there were 10 patients (15.2%) with bedridden status develop severe hypoglycemia compared to none of them (0%) in non-severe hypoglycemia group (p=0.022). Disablity associated health status may be obstacle to self-management when faced to severe hypoglycemic event that why our team invented novel hypoglycemic watch for warning hypoglycemia.
A wide range of information technology (IT) based interventions such as distance learning, diabetes registries, personal or electronic health record systems, clinical information systems, and clinical decision support systems have so far been used in supporting diabetic care. Rajavithi Hospital developed registry system since 2011 to explored the management outcome of diabetes of DMS hospitals more than 34K diabetes patients were report during 2012-2014, applying modern software for real time result display followed by nation diabetes KPI about both good-controlled and uncontrolled KPI in urban hospital area around Bangkok. This registry program we can respond to individual team who responsibility to their area allocated and improved their activity process by each team.
Integrate diabetes healthcare mobility by Diabetes Registry and Smart hypoglycemic warning watch for emergency diabetes management (Phase IV) during 2016-2017. Our propose to promote diabetes self-management program in emergency respond such as hypoglycemia event to decrease admitted cost for hypoglycemia by use innovative device and mobility service by overall decrease cost to 1.5 million baht per year.

11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

“We shall reign with righteousness for the benefits and happiness of the Siamese people.”
This declaration, spoken by His Majesty at his coronation ceremony was his first public pledge to promote the welfare of all his subjects. His Majesty never simply issues instructions or gives orders. The impetus always comes from the local people. Before he makes any proposal, His Majesty first studies the available data and talks to the people involved. He then consults with officials and academics before passing the initiative on to the government. All royal development projects have started in this way.
Furthermore, periods of significant socioeconomic and demographic transition need approaches that are explicitly designed to be temporary and flexible in the face of change, and this also has implications for investments in institutional and human development. In addition, industrialization and urbanization are bringing new problems associated with rapid growth in the absence of adequate regulatory capacity. These include the negative health impacts of air, water, and soil pollution from industry and high-input agriculture, as well as new infectious diseases and zoonoses associated with changing lifestyles and livestock-rearing activities. it is questionable whether reproducing a developed country model that emphasizes high cost curative care over prevention is desirable.
Our team used His Majesty concept by “development must burst from within.” In contrast to the top-down solutions those never seem to work. Our initiative idea is going from the bottom to the top, from the smallest unit and expanding ever wider. Make it easier for people to hold government accountable on diabetes service by providing information to solve their serious problems improvement especially in poverty and vulnerable patients.

12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)

The global community is facing an increasing number of protracted humanitarian crises, which have a significant impact on persons with disabilities. Hypoglycemia emergency situations increase the number of disabling factor of diabetes patients, and also heighten the risks and vulnerabilities that persons with disabilities face as they seek out assistance, support and protection. Hypoglycemic patient with disabilities are among the most marginalised and excluded groups in emergency situations, experiencing widespread violations of their rights. In crises, persons with disabilities have the same basic needs common to all those affected, in addition to specific needs related to disability. The relationship between disability and innovation is rich and complex, deserving careful elaboration and interrogation. In suggesting this, I am aware that there are also fundamental problems that innovation raises in its new policy forms. There are the issues of what is at stake when the state is redefining its traditional obligations towards citizens through innovation frameworks and discourses. In community level we can integrated innovation for assisted hypoglycemic patient especially in co-morbidity such as stroke, disabilities from diabetes foot amputation that not seek out assistance and prevent them loss. We move to integrated new innovation for Gestational diabetes patient to improved maternal healthcare during pregnant and provided best service to improve childbirth healthcare in diabetes national policy in next 5 years.